Association of Short Interpregnancy Interval with Adverse Perinatal Outcomes

Laureane Alvelo-Maldonado, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico

A short interpregnancy interval is one of the factors that have been recently associated with adverse perinatal outcomes. However, it is still unclear whether it is an independent risk factor or whether the association is due merely to confounding by maternal characteristics. Aim: To evaluate the association between short interpregnancy intervals and three perinatal outcomes (low birth weight, preterm birth and small size for gestational age) in Puerto Rican women aged 13-34 years. Birth certificates of women aged 13-34 years who delivered singleton infants during the period 1990 through 2002 in Puerto Rico were analyzed (409,317 live births). Three separate logistic-regression models were used to determine the magnitude of the association between short interpregnancy interval (<6 months), low birth weight (><2,500 g), preterm birth (><37 weeks of gestation) and SGA (><10th percentile of weight for infants with the same sex and gestational age) controlling for sociodemographics, toxic habits, reproductive history, obstetric history, medical risk factors during pregnancy, complications during labor and congenital anomalies.

As compared with women with 18-23 month interpregnancy intervals, those with ><6 month intervals had higher risks of low birth weight (IOR =1.24, 95% CI=1.17-1.30), preterm birth (IOR=1.30, 95% CI=1.25-1.35) and SGA (IOR=1.28, 95% CI =1.23-1.33) after adjusting for potential confounders. Short interpregnancy intervals are significantly associated to perinatal outcomes. These data underscore the need to educate Puerto Rican women regarding birth spacing in order to achieve better pregnancy outcomes. esire for a better life and job provide additional insights into their lives. These findings, and their relevance for health literacy, will be discussed.

Chi Chiao, MSc, MSPH, University of California at Los Angeles School of Public Health, Department of Community Health Sciences

Since STI is a co-factor of HIV/AIDS, a routine sexual health check-up for female sex workers (FSWs) is considered to be a crucial health preventive behavior for detecting STIs at early stage and reducing the risk of contracting HIV. This study explores the social and structural determinants of medical appointment-keeping adherence for FSWs in the Philippines . Specifically, we examine the relative impact of individual demographic, socioeconomic, family characteristics and establishment traits on the likelihood of FSWs' missed scheduled appointments using a multilevel analytical approach. Multiple sources of information were used, including data from the medical records, face-to-face interviews of FSWs and their managers, respectively, and a contextual data recorded from outreach workers.

By calculating intra-class correlation, 60% of the variance of the compliance rate occurred between establishments (p<.0001). Controlling for the individual-level factors, we also found establishment history and condom use policy are most significant predictors of adherence to medical appointments for FSWs. For the establishment with a condom use policy, the average compliance rates are 12.8% higher on the compliance measure (p><.05) compared to establishments without a policy. For each year of workplace history, the average compliance rate of the establishment increases by 1.4% (p><.05). The findings indicate that establishment background is an important determinant of adherences to kept medical appointments for FSWs, even in the presence of controls for a large number of observed characteristics of individuals, families, and workplaces. Implications for interventions aimed at increasing medical adherence will be discussed.

Abstract 3

Tabletop Exercises with Local Health Departments to Assess Bioterrorism Preparedness

Tabletops are excellent needs assessment exercises because they illustrate agencies' strengths and weaknesses and function as a way to look for target development methods. Smallpox is specifically considered an excellent topic for preparation trainings because of the potential devastating impact it could have on the public's health. The Utah Division of Emergency Services and Homeland Security (DES), in conjunction with the Utah Department of Health (UDOH), conducted eight smallpox tabletop exercises throughout the state of Utah in the summer of 2003 to promote bioterrorism response planning among local health departments, local government, state agencies, hospitals, law enforcement, fire, military, media and non-profit organizations.

These exercises revealed to participants the complex range of issues that will be raised during a bioterrorism event. Participants realized that it is crucial for them to understand what their expected roles and responsibilities will be prior to an event occurring. These tabletop exercises highlight the importance of utilizing a multidisciplinary approach to respond to a bioterrorism event. It is crucial for these agencies to be familiar and comfortable with each other and their plans prior to an emergency to ensure a synchronized response to any public health disaster. Health department staff and resources may be quickly overwhelmed in a smallpox outbreak and may require assistance from outside agencies. It is important for pertinent agencies, including the health department, to identify resources that could provide assistance in a public health emergency prior to one occurring.

Abstract 4

Fruit and Vegetable Availability and Consumption Among Rural Parents Who Frequently Eat Away From Home

This abstract utilizes data from High 5 for Kids, a community based dietary change program for parents of preschool children who reside in rural, southeastern Missouri. Parents (n=1254) were primarily young (MN age 28.9 + 7.1), white (77%), overweight (57% with a Body Mass Index (BMI) over 25; MN BMI 27.1+6.2) females (99%) with 59% reporting annual household incomes under $35,000. Thirty-five percent of parents consumed five or more fruits and vegetables (FV) daily (MN intake 4.1+2.1) excluding French fries. Despite twenty-two percent of parents reporting low availability of FV in the home, the main barrier cited to FV intake was taste (44%), not lack of availability in the community (7%). Thirty-eight percent of parents consume food outside of the home 17 or more times per month. The main reason cited for consuming food away from home was convenience (52%). Parents who reported low availability of FV in the home had an increased frequency of food consumption outside of the home (p=0.001). The more often parents eat out, the lower their intake of FV (r=-.09; p=.001) excluding French fries. Eating out was not significantly correlated with weight (r=0.005; p=0.873). Interventions need to consider the influence of foods consumed away from the home among high-risk populations and efforts should be made to improve the quality of the home food environment and address barriers to FV intake.

Abstract 5

Development, Pilot Testing, and Validation of a Knowledge, Awareness, and Practices (KAP) Survey for an Oceanfront Injury Prevention Project

Kennon Kirk, Eastern Virginia Medical School

In a study conducted at the Virginia Beach , VA oceanfront during the summer of 2003, physicians from the Emergency Department at Children's Hospital of the King's Daughters in Norfolk , VA identified several risk factors that were significantly associated with the occurrence of pediatric oceanfront injuries. The risk factors identified were 1) having more than three children in a group, 2) cloudy weather, 3) choppy water, 4) use of sports equipment, and 5) the child having had a water safety class. With support from the National Center for Injury Prevention and Control, a division of the Centers for Disease Control and Prevention, researchers are working with a local health coalition to develop and implement an educational intervention to reduce the incidence of pediatric injuries at the Virginia Beach , VA oceanfront. To evaluate the impact of the intervention, a Knowledge, Awareness, and Practices (KAP) Survey will be used to assess pre- and post-intervention changes in participants' knowledge and behavior. The aim of this study is to develop, pilot test, and validate the KAP survey prior to its administration. Survey content will address items unique to the Virginia Beach oceanfront project as well as information relevant to any intervention designed to reduce oceanfront injuries. Survey validation will involve qualitative survey review and test-retest analysis. Results from this survey validation study will be available by May 29th, 2004.

Ovarian cancer is the fifth most commonly diagnosed non skin cancer in adult women in the United States . The wide international variation in ovarian cancer incidence suggests a significant role for environmental factors, including diet, in the etiology of this disease. We prospectively examined the relationship between dairy consumption and, calcium intake, and vitamin D intake and the risk of ovarian cancer. This study was conducted within the Breast Cancer Detection Demonstration Project (BCDDP) Follow-up cohort, a prospective cohort study begun in 1979, including 31,926 women. We assessed usual dietary intake using a 62-item block food frequency questionnaire. Cox proportional hazards regression was used to model the relationship between diet and ovarian cancer risk, controlling for potential confounding factors.

HIV testing may be cost-effective in reducing HIV-related morbidity and mortality. Since Malawi is impacted by HIV/AIDS and detection of cases is sub-optimal, reasons clinicians might not offer HIV testing should be identified. The objective of the study was to identify reasons clinicians in Malawi might not offer HIV testing. Design, Setting and Participants: Cross-sectional, descriptive, postal survey techniques with telephone and fax follow-up were used to collect a census of clinicians in Malawi . Demographic information and reasons for not offering HIV tests were solicited. Proportions were calculated for each reason. Logistic regression was used to determine whether responses differed by demographics.

523 of 982 (53.26%) clinicians responded. Mean age was 43.56+/-12.93. The five most common reasons for not offering tests were: inadequate training in HIV counseling (50.29%); patient unready (49.52%); no indication (35.56%); facilities unavailable (35.37%); and insufficient time (28.87%). Of six professional categories, medical assistants were most likely to give the reason inadequate training in HIV counseling (OR 95% CI (2.27, 5.57)) and less likely to give the reason patient not ready (0.382, 0.893). General practitioners were more likely to give the reason patient not ready (1.087, 3.65) and less likely to give the reason testing facility unavailable (0.214, 0.800). Differences in reasons for not offering HIV tests amongst clinician groups were few. Thus development of one general program based on common reasons identified in this study could be effective in increasing HIV testing rates. Further investigation of the identified reasons should be undertaken to facilitate program development.

ed drugs. Conclusions: HIV-prevention strategies should be tailored to address the specific needs and characteristics of rural stimulant users.

Abstract 8

An Evaluation of HealthTrak Georgia in Increasing Health Policy Awareness in Georgia

Candace M. Marshall, Morehouse School of Medicine

In Georgia , there is no centralized source of web-based technology that provides information on health policies. The creation of a web initiative that provides access to current information on healthcare legislation, regulation and policy options for Georgia would help to bring healthcare policy issues to its residents. HealthTrak Georgia , an educational initiative of the Womens Policy Group and HealthCare Foundation of Georgia, was created to increase the awareness of health policy and foster minority community involvement in policy development. HealthTrak Georgia components include a web site that allows consumers to track health care legislation throughout the state in addition to educational forums to discuss prevalent health issues. HealthTrak Georgia emphasizes 12 Priority Areas of Public Health critical to eliminating disparities and improving health outcomes for Georgians. HealthTrak Georgia forums were held in two of the twelve health service delivery regions outlined by the Department of Human Resources. The participants were surveyed to determine their demographics, attitudes and perceptions regarding the forums. Findings indicated that over 50% of the participants were Caucasian women with graduate degrees. 98% of the participants felt that the forums presented relevant health policy issues and would be a valuable resource for health policy education.

Abstract 9

Equine West Nile Virus: Does the Current Passive Surveillance System Work?

Sherry Meeks, University of Oklahoma College of Public Health
Other Authors: Johnny Gilpen and Staci Myers

West Nile Virus (WNV) is a zoonotic infection that was first diagnosed in Oklahoma in 2002 and that often infects equines and humans. The active surveillance was conducted by contacting sixty-nine veterinarians working in fifty-three clinics. The passive surveillance system currently in use in Oklahoma is managed by the Oklahoma State Health Department (OSHD). Twenty-five (36.2%) veterinarians working in sixteen clinics (30.2%) had diagnosed and treated WNV in at least one equine residing in Oklahoma County . Our active surveillance system identified 105 equines diagnosed with WNV in Oklahoma County during 2002, of which 34 (32.3%) had been reported to the OSHD. This is compared to the 72 cases of equine WNV identified by the OSHD.

Our study suggests a difference in reported cases depending on the method of surveillance utilized. Passive surveillance resulted in lower numbers of reported equine cases than active surveillance. This study emphasizes the need for improved surveillance methods when dealing with emerging infectious diseases.

Abstract 10

Socioeconomic Disparity is Linked With Disparity in Type and Availability of Physical Activity Facilities

Melissa C. Nelson, Department of Nutrition, University of North Carolina at Chapel Hill
Other Authors: Penny Gordon-Larsen and Barry M. Popkin

Little is known about environmental determinants of physical activity. This study examined modifiable environmental factors that may contribute to disparities in activity and obesity in the US . This sample included 45,781 census block groups from a nationally representative youth cohort. Using Geographic Information Systems, US Census data were linked with physical activity facilities data (primarily from Digital Yellow Pages). Facilities were categorized by type (e.g., private, public, instructional). Low socioeconomic status (SES) neighborhoods (n=4,144) were those in the highest quintile of minorities, highest quintile of households with income <$30,000, and lowest quintile of households with greater than high school education. High SES neighborhoods (n=2,336) were in the lowest quintile of minority population, lowest quintile of income, and highest quintile of education. Logistic regression predicted the odds that facilities were located in a high versus low SES neighborhood, controlling population density.

Seventy-four percent of low SES neighborhoods had zero facilities compared to 63% of high SES neighborhoods. High SES neighborhoods were more likely to have a variety of facilities types (parks (odds ratio=5.2); public (4.6), instructional (6.0), fee (8.6), and member (30.2) facilities). Youth organizations were not differently distributed between low and high SES neighborhoods. Low SES, high minority neighborhoods were less likely to have a variety of physical activity resources. This inequitable distribution of recreation opportunities may underlie disparities in activity and obesity patterns, and promoting accessible and affordable resources for physical activity in low SES neighborhoods will be an important direction for public policy.

Abstract 11

The Impact of Becoming a Parent on Leisure Time Physical Activity (PA): The CARDIA Study

Emily D. Parker, University of Minnesota

PA is inversely associated with future risk of several diseases including coronary heart disease, diabetes, and some cancers. Changes in life such as parenting and marital status may influence changes in PA differently in men and women, due, for example, to differential time pressures and child care responsibilities. Self-reported leisure time PA, parenting and marital status were measured at baseline (1985/86), and 2,5,7,10, and 15 years later among 2,318 young adult black and white men and women in the CARDIA (Coronary Artery Risk Development in Young Adults) Study who were childless at baseline. PA in arbitrary exercise units was estimated based on frequency and intensity. Parenting status was determined by the total number of children (biological and otherwise) living full-time with the participant. Repeated measures regression was used to predict PA at each follow-up exam.

After adjusting for BMI, alcohol, smoking, education, job and marital status, becoming a parent was associated with a greater decrease in PA among women compared to men (Table). CONCLUSIONS: Having children is associated with a greater reduction in PA among women, than men. Time spent caring for children may help explain differences in leisure time PA among men and women.

Abstract 12

Geographic and Socioeconomic Distribtuion of Risk for Asthma Hospitalization of Adults Living in Allegheny County, Pennsylvania

To be consistent with the Centers for Disease Control's (CDC's) goal to improve local asthma surveillance, we utilized local hospital discharge data to assess the rates and geographic distribution of adult asthma hospitalizations in Allegheny County , Pennsylvania. Hospitalization data was obtained from the Pennsylvania Cost Containment Council. The population of interest was adults 19-64 years of age that had been hospitalized for asthma from 1999-2001 in Allegheny County . Age-adjusted, age-specific, and group-specific rates for asthma hospitalization were assessed for the county. ARC-VIEW GIS mapping software was used to visualize the geographic distribution of these rates in each of the 72 zip codes within Allegheny County . For the zip codes that had “higher than expected” rates, standardized incidence ratios (SIR) with corresponding confidence intervals were calculated.

Adult asthma hospitalization rates for the county were similar to those published by the CDC. The gender and age-related disparity of hospitalizations that is reported by the CDC is also observed. When assessing the rates in each of the 72 zip codes within Allegheny County , 31 zip codes had rates that were higher than expected. Twelve zip codes, located predominantly in the Southeastern quadrant of the county, had rates that were significantly higher. Logistic regression analysis suggests a significant contribution of select socio-economic and demographic characteristics. We find that in Allegheny County there is a geo-specific distribution risk of hospitalization due to asthma which is significantly influenced by socioeconomic factors related to income and demographic characteristics related to race.

Abstract 13

Epidemiology of Anemia Among 4- to 17-month Children

Emily Siegel, Johns Hopkins Bloomberg School of Public Health

Risk factors for anemia have not been characterized for young children in rural Nepal . We described the distribution of hemoglobin and prevalence of anemia in 569 4- to 17-month Nepali children by age, sex, caste, socio-economic status, morbidity, anthropometry, and dietary indicators. Participants were identified from census data collected in one of 30 village development committees (VDCs) in Sarlahi District and enrolled in a placebo-controlled, randomized clinical trial between January and March 2002. Hemoglobin and erythrocyte protoporphyrin (EP) were measured at baseline using a heel prick technique. The mean hemoglobin concentration was 101 g/L +/- 12.5. Among the young children, 60.3 % were anemic (hemoglobin < 105 g/L), 2.0% were severely anemic (hemoglobin < 7.0 g/L), and 74% of the anemic cases were associated with iron deficiency (EP < 70 umol/mol). Growth was delayed; 30.8% were stunted, 18.1% were wasted, and 50.7% were underweight. Bivariate analyses revealed age, caste, socio-economic status, dietary diversity, acute respiratory infection, stunting, and underweight to be associated with hemoglobin concentration and/or anemia. We did not observe sex differences to be present. In multivariate models, age and caste were found to be strong predictors of both hemoglobin concentration and anemia. The 15- to 17-month age group and the three caste groups remained significant (p < 0.05) after controlling for EP. We conclude that moderate anemia is a serious problem among infants in the first two years of life living in rural, southeast central Nepal.

Abstract 14

Squamous Cell Carcinoma in Chronic Ulcers of Hansen's Disease

Malaya Santos, MD, Tulane University

Neurotrophic ulcers, extremely common in Hansen¹s Disease (HD), present a therapeutic challenge as they are chronic, recurrent and difficult to treat. Occasionally squamous cell carcinoma (SCC) can develop in chroniculcers. Three patients with biopsy-proven SCC in ulcers were identified from the records of the National Hansen¹s Disease Program. All had lepromatous HD of at least 20 years duration, inactive at the time they developed SCC, with multiple neurologic deficits and secondary deformities. Malignant degeneration occurred in non-healing ulcers located in the foot or ankle, ranging induration from four to thirty years. Two patients underwent below-knee amputation, and the third, amputation of the affected toe. Histopathologic examination revealed SCC in all three patients. Two patients had good post-operative function with no evidence of metastasis and no recurrence to date. However, the third patient developed metastases to local and regional lymphnodes, and to the lungs, and died 7 months after being diagnosed with SCC. The mechanism of malignant degeneration is not precisely understood, but chronic irritation and infection, with resulting degeneration and regeneration have been implicated, as well as decreased vascularity and a weakened epithelium unable to withstand carcinogens. However, its occurrence reminds us of the need for follow up in treated HD. The poor outcome in our third patient also emphasizes that SCC in trophic ulcers in leprosy, despite an indolent nature, can be lethal. A high index of suspicion is needed, in order to provide early diagnosis and appropriate treatment.

Abstract 15

A Descriptive Study of Cancers in People Living With HIV/AIDS in New York State - Before and After the Introduction of Highly Active Antiretroviral Therapy

Kumara Singaravelu, School of Public Health, University at Albany, SUNY
Other Authors: Alvaro Carrascal, Punkin C. Stephens, Dennis Tsui and Thomas Chesnut

Recent studies have shown the changing epidemiology of cancers in people living with HIV/AIDS (PLWHA), since the advent of Highly Active Antiretroviral Therapy (HAART) in late 1996. This study on the SPARCS (Statewide Planning and Research Cooperative System) hospital discharge data and the Medicaid claims data is to observe the trends of these cancers amongst PLWHA in New York State. Hospital discharges with ICD-9 diagnoses for HIV/AIDS and malignancies were extracted for the years 1994-2002 from SPARCS and using existing screening protocols, Medicaid recipients with HIV/AIDS and malignancies were identified for the years 1993-2001. The years 1996 and before were classified as pre-HAART, and the years 1997 and after, as post –HAART for further analysis. Rates were calculated per 100,000 hospitalizations with HIV/AIDS for the SPARCS data and per 100,000 Medicaid recipients with HIV/AIDS for the Medicaid claims data.

In both the databases, significant decline in rates was observed for AIDS-related Kaposi's sarcoma, while invasive cervical carcinoma and non-AIDS related cancers of the colon, anus, liver, pancreas, lung, larynx, female breast, prostate, Hodgkin's disease and multiple myeloma showed significant increases in the post- HAART period. With PLWHA living longer, non-AIDS related cancers may be an increasing cause of morbidity and mortality in these patients. PLWHA, clinicians and policy makers need to be made aware of these changing risks in PLWHA to institute appropriate screening and prevention measures.

Abstract 16

Is Asthma Related to Atopic Dermatitis Among Hispanic School Children in Puerto Rico?

Leslianne Soto-Class, Graduate School of Public Health, Department of Biostatistics and Epidemiology, Medical Sciences Campus, University of Puerto Rico

Asthma and atopic dermatitis are diseases that are increasing in United States and worldwide especially among schoolchildren. In Puerto Rico the prevalence of both diseases on children are unknown. It is important to determine if there is an association between asthma and atopic dermatitis. For this reason a cross-sectional study was designed to estimate the asthma prevalence on schoolchildren in a coastal municipality (Humacao) of Puerto Rico. The study population consisted of all children attending the second grade of privates and public schools in the School District of Humacao. A questionnaire, designed by the International Study of Asthma and Allergies in Children (ISAAC), was modified and validate to determine the prevalence of asthma and atopic dermatitis. The questionnaire was sent with the children to the parents for its completion. The response rate was 52%. To evaluate the possible correlation between both diseases the prevalence odds ratio was estimated. The prevalence odds ratio was 3.19 (IC 95%: 1.94, 5.25). A logistic regression model was used to evaluate the relation of asthma and atopic dermatitis. The prevalence of both diseases was high; the prevalence of asthma was 21.5% and the prevalence for atopic dermatitis was 22.3%. The results of this study points out that further research should be conducted to evaluate not only the biological plausibility of the observation but also the inclusion of both criteria in any health intervention geared toward this highly susceptible population.

It is well-established that injuries are a leading cause of mortality in the US and strong associations between injury mortality and degree of rurality have been demonstrated. However, a description of the disparities in non-fatal injury rates by rurality is currently lacking. The National Health Interview Survey (NHIS) is an ongoing, nation-wide, survey that monitors the health of the noninstitutionalized civilian population each year based on a multistage probability sampling design. Using data from the 1997-2001 NHIS, we examined nonfatal injury rates using four levels of rurality. All participants aged 18 to 65 years of age who had a non-fatal medically attended injury were selected for the analysis. Rates per 1000 persons and their associated standard errors were computed using SUDAAN. Counties were coded according to Urban Influence Codes (UIC) and were categorized into four groups; large urban, small urban, suburb with some urban influence, and rural. Preliminary data indicate that the rural counties have injury rates of 121.3, which are 27% higher than the large urban counties. Higher rural rates persisted within all income and gender categories as well as within persons of Caucasian race, younger age groups and higher education categories. Rural counties also experienced higher rates for falls and overexertion injuries as well as injuries sustained while engaged in leisure activities or work around the house. The results suggest that rural residents have uniformly higher injury rates and potentially have unique risks for injury morbidity. Understanding why these differences exist should be a priority for researchers.

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